Volume 9 Number 3 Fall 2010 International Student Journal The off NNurse AAnestthhesiia TOPICS IN THIS ISSUE Septic Shock & Methamphetamine Use Local Anesthesia for Knee Arthroscopy Congenital Heart Malformations Resppiratoryy Distress Syyndrome Post-dural Puncture Headache Peripartum Cardiomyopathy Maxillomandibular Fixation Trigemino-cardiac Reflex HHypogllossall NNerve IInjjury Osteogenesis Imperfecta Mitochondrial Myopathy Pulmonary Embolism Sebastian Syndrome Felty’s Syndrome Placenta Accreta Cricoid Pressure INTERNATIONAL STUDENT JOURNAL OF NURSE ANESTHESIA Vol. 9 No. 3, Fall 2010 Editor Vicki C. Coopmans, CRNA, PhD Associate Editor Julie A. Pearson, CRNA, PhD Editorial Board Carrie C. Bowman Dalley, CRNA, MS Georgetown University Janet A. Dewan, CRNA, MS Northeastern University Rhonda Gee, CRNA, DNSc Decatur Memorial Hospital /Bradley University Michele Gold, CRNA, PhD University of Southern California Robert Hawkins, CRNA, MS, MBA, DNP Naval School of Health Sciences Donna Jasinski, CRNA, DNSc Georgetown University Russell Lynn, CRNA, MSN University of Pennsylvania Maria Magro, CRNA, MS, MSN University of Pennsylvania MAJ Denise McFarland, CRNA, MSN, AN U.S Army Graduate Program in Anesthesia Nursing, Tripler Army Medical Center Greg Nezat, CRNA, PhD Naval School of Health Sciences Teresa Norris, CRNA, EdD University of Southern California Christopher Oudekerk, CRNA, DNP Naval Medical Center, Portsmouth Michael Rieker, CRNA, DNP Wake Forest University Baptist Medical Center, University of North Carolina at Greensboro LCDR Dennis Spence, CRNA, PhD, NC, USN Naval School of Health Sciences Edward Waters, CRNA, MN California State University - Fullerton, Kaiser Permanente School of Anesthesia Lori Ann Winner, CRNA, MSN University of Pennsylvania Kathleen R. Wren, CRNA, PhD Florida Hospital College of Health Sciences Contributing Editors For This Issue Darla A. Adams, CRNA, PhD University of North Dakota Kevin C. Buettner, CRNA, MS University of North Dakota Gary Clark, CRNA, EdD Webster Univeristy Sass M. Elisha, CRNA, EdD California State University - Fullerton, Kaiser Permanente School of Anesthesia Joseph Joyce, CRNA, BS Wake Forest University Baptist Medical Center, University of North Carolina at Greensboro Mike Sadler, CRNA, MSNA Texas Christian University Denise Tola, CRNA, MSN Georgetown University 1 Reviewers For This Issue Matthew Bishop, CRNA, MSN Tripler Army Medical Center Courtney Brown, CRNA, MSN Wake Forest University Baptist Medical Center, University of North Carolina at Greensboro Kevin Buss, CRNA, MS Uniformed Services University Graduate School of Nursing Connie Calvin, CRNA, PhD Northeastern University Marjorie A. Geisz-Everson, CRNA, PhD Louisiana State University Health Sciences Center Stephanie Fan, CRNA, MSN Washington University School of Medicine; St. Louis, MO Michael Neill, CRNA, MSN Tripler Army Medical Center Johanna Newman, CRNA, MS Florida Hospital College of Health Sciences Washington University School of Medicine; Ilene Ottmer, CRNA, MSN St. Louis, MO Jesse Rivera, CRNA, MSN Naval Hospital; Camp Pendelton, CA CPT Priscella Shaw, CRNA, MSN Tripler Army Medical Center, HI Lori Stone, CRNA, MSN Decatur Memorial Hospital /Bradley University Denise Tola, CRNA, MSN Georgetown University The opinions contained in this journal are those of the student and do not necessarily represent the opinions of the program or the University Disclaimer for all articles authored by military personnel: The views expressed in this journal are those of the authors and do not necessarily reflect the official policy or position of their respective Military Department, Department of Defense, Uniformed Services University of the Health Sciences nor the U.S. Government. The work was prepared as part of the official duties of the military service member. Title 17 U.S.C. 105 provides that ‘Copyright protection under this title is not available for any work of the United States Government’. Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties. Front Cover: Mimi Brown, RN, BSN, a graduate students enrolled in the Goldfarb School of Nursing at Barnes-Jewish College Nurse Anesthesia Program practices central line insertion in the Center for Simulation. (Photograph by Chris Tobnick, BA). The Guide for Authors: can be found at www.aana.com by following this path: Professional Development > Nurse Anesthesia Education > For Students (Scroll to the bottom of the page) > Guide for Authors Or, use this direct link: http://www.aana.com/studentjournal.aspx 2 Table of Contents Case Reports Cricoid Pressure During Rapid Sequence Induction .................................................................5 Melissa J. Davey, Northeastern University Anesthesia Considerations for Placenta Accreta ........................................................................8 Melissa VanMatre, University of North Dakota Hypoglossal Nerve Injury Following Airway Manipulation ....................................................12 Eva Marie Jorden, Texas Christian University Anesthesia Management for Sebastian Syndrome ....................................................................15 Jennifer Henjum, University of North Dakota Septic Shock and Habitual Methamphetamine Use .................................................................17 Lee Ranalli, Kaiser Permanente School of Anesthesia Suspected Trigemino-Cardiac Reflex During Pediatric Tonsillectomy ..................................21 Jason Goff, Uniformed Services University of the Health Sciences Treatment of Post-Dural Puncture Headache with Ketoralac ................................................24 Chad Moore, Uniformed Services University of the Health Sciences Intraoperative Pulmonary Embolism ........................................................................................27 Laurel Schooler, University of Southern California Anesthetic Management of Felty’s Syndrome ...........................................................................30 Felicity Rensberger, University of Southern California Anesthesia for Maxillomandibular Fixation .............................................................................34 Christopher D. Kyle, Georgetown University Acute Respiratory Distress Syndrome in the Cardiac Patient ................................................37 Lyndsay A. Bikul, Kaiser Permanente School of Anesthesia Undiagnosed Peripartum Cardiomyopathy ..............................................................................41 Ashleah Pope, University of Southern California Management of the Pediatric Patient with Osteogenesis Imperfecta .....................................44 Benjamin Lindsey, University of Southern California Mitochondrial Myopathy: Designing an Anesthetic Plan ........................................................47 Kathryn W. Phares, Wake Forest University Baptist Medical Center, University of North Carolina at Greensboro 3 Local Anesthesia and Sedation for Knee Arthroscopy .............................................................50 Johnny K. Cheng, University of Southern California The Patient with Complex Congenital Heart Malformations..................................................53 Crystal M. Alber, Webster University 4 Cricoid Pressure During Rapid Sequence Induction Melissa J. Davey, BSN Northeastern University Keywords: cricoid pressure, rapid sequence Preoperatively, the patient stated that she induction, Sellick’s maneuver, BURP, bi- was easily nauseated and had a history of manual laryngoscopy motion sickness. A scopolamine patch 1.5 mg was placed behind the left ear. An 18- Cricoid pressure, also known as Sellick’s gauge peripheral intravenous catheter was maneuver, was first described in 1961.¹ The placed in the left forearm. Midazolam 2 two main purposes for applying cricoid milligrams (mg) was administered pressure are prevention of gastric intravenously (IV) in divided doses followed regurgitation during induction of anesthesia by metoclopramide 10 mg IV. The patient and prevention of gastric insufflation during entered the operating room and a pulse positive pressure ventilation.² Sellick oximeter, non-invasive blood pressure cuff, described his maneuver as “occlusion of the and a 5-lead electrocardiogram were upper esophagus by backward pressure on applied. She was preoxygenated via a face the cricoid ring against the bodies of mask. Intravenous induction followed with cervical vertebrae to prevent gastric contents lidocaine 80 mg, propofol 200 mg, fentanyl from reaching the pharynx.”¹ This technique 50 micrograms (mcg), and succinylcholine quickly gained acceptance as an adjunct for 90 mg. Cricoid pressure was lightly applied rapid sequence intubation. However, the by the surgeon while the patient was awake application of cricoid pressure does not and then firmer pressure applied upon loss always prevent gastric regurgitation during of consciousness. A rapid sequence the induction of anesthesia, and its utility intubation followed. A direct laryngoscopy has been questioned.³ was performed with one attempt using a Macintosh 3 blade. Initially, a grade 3 Case Report Cormack and Lehane view was visualized by the laryngoscopist. A modified A 55 year old, 47 kg, 63 inch female with a backward-upward-rightward pressure diagnosis of right breast cancer presented for (BURP) maneuver was then applied wire-localized lumpectomy and sentinel improving the view of the laryngoscopist to node mapping and biopsy. Past medical grade 2. A bougie was requested. Bimanual history consisted of a hiatal hernia, laryngoscopy was performed by the gastroesophageal reflux disease (GERD), anesthetist which optimized the laryngeal Shatzki ring, osteoporosis, and depression. view to a grade 1. The laryngoscopist Home medications consisted of lorazapam, provided instruction to the surgeon to assist multivitamin, magnesium, calcium, vitamin with laryngeal manipulation and the trachea D, blue-green algae supplement, and was intubated successfully with a 6.5 oral enterozyme. Airway exam resulted in a cuffed endotracheal tube. The endotracheal Mallampati class 2 score. Thyromental tube was taped securely at 21 centimeters distance was assessed as two fingerbreadths (cm) positioned at the teeth. An additional and the patient had a small mouth opening 60 mg of propofol and 75 mcg of fentanyl with large frontal incisors. were administered intravenously throughout the case, each in divided doses. 5 Dexamethasone 6 mg IV was administered between the cricoid cartilage and cervical after induction of anesthesia and spine. This is thought to cause occlusion of ondansetron 4 mg IV administered 30 the esophageal lumen, thus preventing minutes prior to completion of the regurgitation of gastric contents.5 In an procedure. Neuromuscular blockade was observational study by Smith et al. (2003) achieved with cis-atricurium 6 mg and using magnetic resonance imaging, the antagonized with neostigmine 3 mg esophagus was lateral in more than 50% of administered concomitantly with the sample in the absence of cricoid glycopyrrolate 0.6 mg upon completion of pressure. Furthermore, Smith’s group found the procedure. Anesthesia was maintained that the esophagus was displaced laterally in with 1.5% end-tidal sevoflurane. A more than 90% of the sample upon bispectral index monitor and nerve application of cricoid pressure.5In this study, stimulator were used. The patient received the head was placed in a neutral position, two liters of lactated ringers intravenously. which could possibly allow the esophagus to At the end of the procedure, the patient was be more mobile, as opposed to the head awake and responsive to verbal commands, being fully extended when Sellick first breathing spontaneously, and maintaining described the use of cricoid pressure. tidal volumes between 5 to 10 L/min. The However, the head is rarely placed in a fully patient demonstrated a sustained head lift, extended position, but rather in a neutral or and airway reflexes were present. The sniffing position to optimize the trachea was extubated without difficulty. visualization of the larynx. Therefore, the The patient was able to move herself onto findings of Smith et al. may be more the stretcher with minimal assistance and generalizable in the clinical setting. In an was transferred to the recovery room on 6 L opposing study by Rice et al. (2009) using of oxygen administered by face mask. magnetic resonance imaging, the head was placed in sniffing, neutral, and extended Discussion positions. The origin of the esophagus is found to be inferior to the level of the Cricoid pressure, originally described by cricoid cartilage.6 The lateral displacement Sellick in 1961¹, is used to prevent passive of the esophagus still occurs, however, the regurgitation and possible aspiration during location and movement of the esophagus is induction of anesthesia. It is usually irrelevant to the effectiveness of Sellick’s reserved for patients with an increased risk maneuver in the prevention of gastric of aspiration when rapid sequence intubation regurgitation. Rice et al. state that it is the is indicated. The technique consists of occlusion of the hypopharynx with the exerting downward pressure with the application of cricoid pressure that is forefinger while preventing lateral essential to the prevention of regurgitation displacement of the cricoid ring by the and aspiration.6 thumb and middle finger.4 There are conflicting data regarding the anatomical Manipulation of the external anatomy of the relationship between the esophagus and cricoid and thyroid cartilages is frequently cricoid cartilage. Theoretically, the used to aid in the optimization of the esophagus lies posteriorly to the cricoid ring laryngeal view. The three commonly used and the application of downward pressure on techniques include the Sellick maneuver, the cricoid cartilage as described should involving cricoid pressure, backward- cause compression of the esophagus upward-rightward pressure (BURP), and 6 bimanual laryngeal manipulation. Studies aspiration remains controversial. The have indicated that some of these commonly amount of pressure applied to the cricoid used techniques may actually worsen the cartilage is universally accepted as 10 glottic view.7-10 newtons (N) in an awake patient followed by an exerted pressure of 30 to 40 N upon BURP was first introduced in 1993 by loss of consciousness. Multiple studies have Knill.7 The BURP technique involves indicated that a knowledge deficit exists direction and pressure applied to the thyroid among assistants providing the necessary cartilage by an assistant to improve glottic amount of pressure to the cricoid cartilage, view by the laryngoscopist7The efficacy of as well as the appropriate location of this technique was supported by a study anatomical structures. In a non- conducted by Takahata et al. in which an experimental, correlational, descriptive improvement in glottic view was seen in 630 study, Beavers et al. provided a formalized cases.8 Snider et al. conducted a study which training program to improve knowledge and combined BURP and Sellick’s maneuvers in skills in medical personnel assisting with the an attempt to improve the glottic view application of cricoid pressure. The study during a rapid sequence induction of demonstrated that the participants were anesthesia, while providing protection unable to retain their knowledge and skills against passive gastric regurgitation. The after eight months. 11 results of this study indicated that a modified BURP maneuver worsened the Despite the controversy surrounding the use laryngeal view in 30% of the cases and was of cricoid pressure during a rapid sequence of no benefit during rapid sequence induction, it is still regarded as a standard of induction.9 care. In 1991, a judge in the United Kingdom ruled against an anesthetist for Bimanual laryngoscopy involves failing to provide cricoid pressure to a manipulation of the thyroid cartilage patient with an irreducible hernia who performed by the laryngoscopist with regurgitated and aspirated.12 In a recent concurrent direct observation of the larynx. editorial by Lerman, he states that “the legal After the view is optimized, the laryngeal community exploits its omission from the manipulation is delegated to an assistant, anesthetic record as evidence of a practice allowing the laryngoscopist’s right hand to below the ‘accepted’ standards” despite place the endotracheal tube.10 Levitan et al. having a Grade D recommendation”.3,13 In conducted a randomized trial comparing addition to the application of cricoid cricoid pressure, BURP, and bimanual pressure during a rapid sequence induction, laryngoscopy. The results of the study other measures should be considered in indicated that bimanual laryngoscopy is reducing the risk of regurgitation and more effective at improving laryngeal view aspiration, such as minimizing preoperative than BURP or cricoid pressure. The study intake, pharmacologically increasing gastric also indicated that the use of BURP and emptying, and reducing gastric volume and cricoid pressure frequently worsen acidity.4 In the case described, Sellick’s laryngoscopy view.10 maneuver was applied as part of a planned rapid sequence induction and The efficacy of applying cricoid pressure metoclopraminde was given pre operatively during a rapid sequence induction in patients to hasten gastric emptying.. When the at increased risk for gastric regurgitation and laryngeal view proved to be difficult, the 7 laryngoscopist found that, as supported by Cricoid pressure results in compression the literature, bimanual laryngoscopy of the postcricoid hypopharynx: the afforded a grade one view that was not esophageal position is irrelevant. Anesth obtained using cricoid pressure or the BURP Analg. 2009;109:1546-1552. maneuver. 7. Knill RL. Difficult laryngoscopy made easy with a “BURP”. Can J Anaesth. References 1993;40:279-282. 8. Takahata O, Kubota M, Mamiya K, et al. 1. Sellick BA. Cricoid pressure to control The efficacy of the “BURP” maneuver regurgitation of stomach contents during during a difficult laryngoscopy. Anesth induction of anaesthesia. Lancet. Analg. 1997;84:419-421. 1961;2:404-406. 9. Snider DD, Clarke D, Finucane BT. The 2. Salem MR, Sellick BA, Elam JO. The “BURP” maneuver worsens the glottic historical background of cricoid pressure view when applied in combination with in anesthesia and cricoid pressure. Can J Anaesth. resuscitation. Anesth Analg. 2005;52:100-104. 1974;53:230-232. 10. Levitan RM, Kinkle WC, Levin WJ, 3. Neilipovitz DT, Crosby ET. No evidence Everett WW. Laryngeal view during for decreased incidence of aspiration laryngoscopy: a randomized trial after rapid sequence induction. Can J comparing cricoid pressure, backward- Anaesth. 2007;54:748-764. upward-rightward pressure, and 4. Ogunnaike BO, Whitten CW. bimanual laryngoscopy. Ann Emerg Gastrointestinal disorders. In Barash PG, Med. 2006;47:548-555. Cullen BF, Stoelting RK, Cahalan MK, 11. Beavers RA, Moos DD, Cuddeford JD. Stock MC, eds. Clinical Anesthesia. 6th Analysis of the application of cricoid ed. Philadelphia:Lippincott Williams & pressure: implications for the clinician. J Wilkins; 2009:1223-1224. Perianesth Nurs. 2009;24:92-102. 5. Smith KJ, Dobranowski J, Yip G, 12. Vanner R. Cricoid pressure. Int J Obstet Dauphin A, Choi PT. Cricoid pressure Anesth. 2009;18:106-110. displaces the esophagus: an 13. Lerman J. On cricoid pressure: “may the observational study using magnetic force be with you”. Anesth Analg. resonance imaging. Anesthesiology. 2009;109:1363-1366. 2003;99:60-64. 6. Rice MJ, Mancusco AA, Gibbs C, Mentor: Janet A Dewan, CRNA, MS Morey TE, Gravenstein N, Deitte LA. Anesthesia Considerations for Placenta Accreta Melissa VanMatre, MS University of North Dakota Keywords: placenta accreta, placenta frequent cesarean section deliveries.1 previa, maternal hemorrhage, anesthesia Statistically it occurs in 1 out of every 533 deliveries.2 Parturients are at an 11% risk of Placenta accreta, a relatively rare condition, this condition when associated with placenta is increasing in incidence as a result of more previa and prior cesarean delivery.2 8 According to Gabbe et al, the “risk rises to with methergine 0.2 mg IM, one unit of 67% when placenta previa occurs with a specific PRBC, and hespan 500 ml. Despite history of four or more cesarean treatment, rapid blood loss continued and deliveries”.2 Massive hemorrhage, the patient’s BP subsequently dropped to disseminated intravascular coagulation, 60/29, HR 115. Ephedrine and urinary and renal complications, and phenylephrine were administered IV and a respiratory distress syndrome are some of phenylephrine infusion was initiated as the the major morbidities resulting from patient began to lose consciousness. At this placenta accreta.3 time, the surgeon determined an emergent hysterectomy would be necessary for Case Report inability to control intraoperative hemorrhaging. A 25 year old gravida 4 parity 3 at 37 weeks gestation presented for cesarean section due Conversion to a general anesthetic was to diagnosed placenta previa. Patient initiated with etomidate 14 mg and weighed 80kg and measured 58in.. She had succinlycholine 100 mg. A second unit of no significant health history with previous type specific PRBC was administered and a anesthesia for tonsillectomy and three prior unit of O negative PRBCs was initiated due cesarean sections with no anesthesia to continued hemorrhage. A diagnosis of complications. placenta percreta was made at this time. A central and arterial line were placed under Preoperative laboratory values included; ultrasound guidance. Four units fresh frozen hemoglobin (Hgb) 9.2 g/dl, hematacrit (Hct) plasma (FFP) and 6 units of platelets were 27.2%, and platelet count 222 x1000/mm3. administered. Calcium chloride 500 mg IV An ultrasound completed 8 days prior was administered after completion of 7 units indicated complete placenta previa. The PRBCs. Full body forced air warmers and patient was typed and crossed for 2 units fluid warmers were instituted for a patient packed red blood cells (PRBCs). temperature of 34.4 oC. Following the 8th The anesthetic plan was cesarean section and final unit PRBCs, laboratory results under spinal anesthetic. The patient were as follows: Hgb 10.1g/dl, Hct 29%, presented to the operating room in stable platelet count 83 x1000/mm3 , PT 14.9 s, and condition with a 20 gauge (g) peripheral IV PTT 32 s. Estimated blood loss totaled 5,000 and an additional 16g PIV was inserted. A ml. The endotracheal tube was removed spinal block consisting of 0.75% after the patient was awake. She was then bupivacaine 1.6 ml, fentanyl 25 mcg, and transferred to the post anesthesia care unit duramorph 0.15 mg was administered with stable vital signs. without difficulty and the patient was medicated with phenylephrine 100 mcg for a Discussion 20% drop in baseline blood pressure. The baby was delivered without incident with an Placenta accreta is an abnormal formation of incision to delivery time of 8 min. Pitocin 20 the placenta that can present in three forms. units was injected into the infusing IV fluids Placenta accreta vera is the development of following cord clamping. the placenta on the surface of the uterine muscle. Significant blood loss was then noted in the suction canister. The patient was medicated 9